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COMMERCIAL AUTO INSURANCE TEXAS - Business Auto Policy
SECTION I - GENERAL INFORMATION Preferred Method Of Contact
Your Name:(Required Field)
Business Name:
Street Address:
City:
State:	MUST be TEXAS!
Zip/Postal:
County:
E-Mail:(Required Field)
Phone:(Required Field)
Fax (optional):
Currently Insured? (If yes, list carrier, and # of years continuous. If no, type NONE)
Type of Business: (Please be specific, and tell how vehicles are used.)
Radius of Operation: (How Many Miles Radius Will the Vehicles be Used?)
Will the vehicles be used for business only, or business and personal?	business use only personal & business use
Owner's Name:
Owner's Social Security Number:
Owner's Birthdate:
Owner's Address:
Effective Date Desired:

Please list below any unique coverages or exposures that are not listed on this quote form.

SECTION II DRIVER LIST: (if more than nine drivers, list in remarks)
Driver #	Name	Male or Female	Date of Birth	Marital Status	List tickets or Accidents in 3 years	Does Driver Need SR22?
1						Yes
2						Yes
3						Yes
4						Yes
5						Yes
6						Yes
7						Yes
8						Yes
9						Yes

SECTION III INSURANCE COVERAGES:
Combined Limits of Liability:	$100,000 $300,000 $500,000 $1,000,000
Comprehensive Deductible:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible
Collision Deductible:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible
Do you want Medical Coverage?	Yes No
Do you want Uninsured Motorist Coverage?	Yes No

SECTION IV COMMERCIAL VEHICLE LIST: (if more than nine vehicles, list in remarks)
Veh#	Year	Make/Model	Body Type.	G.V.W.	Cost New	Vehicle ID(VIN#)	Comp & Collision
1							Yes
2							Yes
3							Yes
4							Yes
5							Yes
6							Yes
7							Yes
8							Yes
9							Yes
List Special Equipment & Values (i.e., rack, tool box, etc. per vehicle)

Thank you for filling out this form COMPLETELY!
Please note that no coverage can be bound, modified, or cancelled without signatures.

Your Privacy is Our Priority
All information that you provide is used strictly for the purpose of providing you with a quote. We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not sell, give or otherwise transfer your data to ANY other person or entity for sales, marketing, or ANY other purposes, other than the insurance companies, agents and representatives that will provide you with a quote. By checking the box below you agree to allow our agency to use your information to provide you an insurance quote. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send a
Commercial Vehicle Quote!

Email Address (confirmation required for form submission)

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